What are the immediate post cardiac arrest care orders?

Immediate Post-Cardiac Arrest Care Orders

The immediate post-cardiac arrest care should include a comprehensive, structured, multidisciplinary system focusing on hemodynamic stabilization, ventilation optimization, targeted temperature management, and neurological monitoring to improve survival and neurological outcomes. 1

Initial Assessment and Monitoring

Airway and Ventilation

• Secure airway with endotracheal intubation if not already in place
• Avoid excessive ventilation:
  • Target 10-12 breaths/minute
  • Titrate to PETCO₂ of 35-40 mmHg 1
  • Use continuous capnography
• Oxygen management:
  • Initially use highest available oxygen concentration 1
  • Once SpO₂ can be measured, titrate FiO₂ to maintain SpO₂ 94-98% 1
  • Avoid hyperoxia (SpO₂ 100%) when possible 1
• Position head of bed at 30° if tolerated to reduce cerebral edema and aspiration risk 1

Hemodynamic Support

• Establish IV/IO access if not already in place
• Initial fluid resuscitation:
  • 1-2 L normal saline or lactated Ringer's 1
  • Consider 4°C fluid if initiating therapeutic hypothermia
• Target MAP ≥65 mmHg (preferably >80 mmHg) 1, 2
• For hypotension (SBP <90 mmHg), initiate vasopressors:
  • Norepinephrine: 0.1-0.5 mcg/kg/min (titrate to effect) 3
  • Dopamine: 5-10 mcg/kg/min (alternative) 1
  • Epinephrine: 0.1-0.5 mcg/kg/min (alternative) 1

Monitoring

• Continuous cardiac monitoring
• Continuous pulse oximetry
• Continuous quantitative capnography
• Arterial line for continuous blood pressure monitoring
• Core temperature monitoring (esophageal, bladder, or rectal) 1
• Central venous catheter for CVP monitoring and medication administration
• Hourly urine output measurement
• Continuous EEG monitoring for comatose patients 1

Laboratory and Diagnostic Studies

Immediate Labs

• Arterial blood gas
• Serum electrolytes (especially potassium)
• Blood glucose
• Complete blood count
• Coagulation profile
• Serum lactate
• Cardiac biomarkers (troponin)
• Toxicology screen if indicated

Imaging

• 12-lead ECG (to identify STEMI or new LBBB)
• Chest X-ray
• Bedside cardiac ultrasound to assess cardiac function and identify reversible causes 2
• Brain CT or MRI (when patient is stabilized) 1

Targeted Temperature Management (TTM)

• For comatose patients (not following commands) after ROSC:
  • Target temperature: 32-36°C 1
  • Duration: maintain for at least 24 hours 2
  • Avoid active rewarming in patients who spontaneously develop mild hypothermia (32°C) 1
  • Prevent fever in all post-cardiac arrest patients 1
  • Avoid shivering (use sedation, neuromuscular blockade if needed)

Treat Reversible Causes (H's and T's)

• Hypovolemia: IV fluids
• Hypoxia: Ensure adequate oxygenation
• Hydrogen ion (acidosis): Ensure adequate ventilation
• Hypo/Hyperkalemia: Correct electrolyte abnormalities
• Hypothermia: Warming if severe
• Tension pneumothorax: Needle decompression if suspected
• Tamponade: Pericardiocentesis if suspected
• Toxins: Antidotes if applicable
• Thrombosis (coronary): Consider emergent coronary angiography for STEMI 1, 2
• Thrombosis (pulmonary): Consider thrombolytics if PE suspected 2

Cardiovascular Management

• Consider emergency coronary angiography for:
  • Patients with STEMI on ECG
  • High suspicion of cardiac etiology
  • Initial rhythm of VF/pulseless VT 2
• For post-cardiac surgery patients:
  • Consider immediate defibrillation for VF/VT
  • Consider immediate pacing if pacer wires are in place for asystole/bradycardia
  • Consider early resternotomy if in appropriate setting 1

Neurological Management

• Maintain sedation for patient comfort and ventilator synchrony
• Treat seizures if they occur:
  • Obtain EEG for diagnosis 1
  • Use standard anticonvulsant regimens 1
• Delay neurological prognostication:
  • At least 72 hours after normothermia in patients treated with TTM 1
  • At least 72 hours after cardiac arrest in patients not treated with TTM 1

Glycemic Control

• Monitor blood glucose frequently
• Avoid both hyperglycemia and hypoglycemia
• Treat significant hyperglycemia (>180 mg/dL) with insulin
• The optimal target range remains uncertain 1

Common Pitfalls to Avoid

• Hyperventilation: Decreases cerebral blood flow and worsens outcomes
• Hyperoxia: May increase free radical formation and worsen reperfusion injury 1
• Hypotension: Associated with increased mortality 2
• Fever: Worsens neurological outcomes
• Premature prognostication: May lead to inappropriate withdrawal of care
• Delayed recognition of STEMI: May miss opportunity for coronary intervention
• Breath stacking in patients with obstructive lung disease: Can lead to auto-PEEP and decreased venous return 1

Implementation of a structured post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization has been shown to improve neurological outcomes and potentially reduce ICU length of stay in survivors 4, 5.